🇨🇿
CZ
HEALTH QUESTIONNAIRE
Full name
Date of birth
Contact details (phone + e-mail)
1. Health status
Current issues (main reasons for the visit)
Chronic illnesses (including diagnoses)
No
Yes
Do you take any medication regularly?
No
Yes
Allergies (medication, food, pollen, etc.)
No
Yes
2. Nervous & mental balance
How would you rate your mental resilience?
Good
Fluctuating
Poor
Occurrence of anxiety, irritability, depression?
Rarely
Sometimes
Often
Sleep quality
Good
Light
Fragmented
Trouble falling asleep
Fatigue
Morning
Afternoon
All day
No fatigue
3. Digestion & elimination
Appetite
Normal
Increased
Decreased
Digestive issues
Bloating
Heartburn
Abdominal pain
Diarrhea
Constipation
Bowel movements
Regular
Irregular
Urination
Normal
Frequent
Nocturnal
Burning
4. Heart, vessels, blood pressure, lymph
Blood pressure
Normal
High
Low
Variable
Cold extremities
Yes
No
Varicose veins
Yes
No
Lymphatic issues (swelling, blocked lymph)
Yes
No
5. Hormonal system
Thyroid disorders
No
Yes
Menstrual cycle (women)
Regular
Irregular
Painful
Heavy / light
PMS / menopause
No
Yes
Changes in sexual energy/libido
Normal
Decreased
Increased
Prefer not to say
Fertility
No issues
Not examined
Issues
Prefer not to say
6. Immunity, inflammation, infections
Recurrent infections (respiratory, urinary, etc.)
No
Yes
Autoimmune diseases
No
Yes
Acne, eczema, rashes, psoriasis, etc.
No
Yes
7. Respiratory tract & allergies
Sinus problems, frequent colds, cough?
No
Yes
Allergies to pollen, dust, animals?
No
Yes
Asthma or respiratory insufficiency
No
Yes
8. Lifestyle & environment
Do you smoke?
No
Occasionally
Regularly
Do you drink alcohol?
No
Occasionally
Regularly
Diet
Mixed
Vegetarian
Vegan
Other
Stress
Low load
Frequent
Long-term overload
Physical activity
Regular
Occasional
Mostly sedentary
Contact with nature
Daily
Sometimes
Not at all
Additional important information
Anything else that should be mentioned?
I agree that my personal data from this questionnaire will be processed solely for the purpose of preparing an individual gemmotherapy plan. The data will not be shared with third parties, and I may request deletion at any time. I understand that gemmotherapy does not replace medical care and only serves as a complement.
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Thank you for your time.
Linda
